Nephron-sparing surgery for adenocarcinoma in a renal allograft.

The incidence of malignant tumors in recipients of renal allografts is higher than in the general population. Renal cell carcinoma (RCC) accounts for 4.6% of the tumors in transplanted patients; of them, only 10% are found in transplanted kidneys. Transplantectomy has always been the usual treatment. However, during the last years, nephron-sparing surgery of the allograft is more frequently done in well-selected cases, and therefore dialysis can be avoided. We report the case of a 37-year-old female patient with renal transplant, diagnosed with a 4.5 cm tumor in the lower pole of the renal allograft. The patient underwent partial nephrectomy successfully. Six years after surgery, there is no evidence of recurrence of the disease and the patient maintains an adequate renal function.

Nephron-sparing surgery for treatment of reninoma: a rare renin secreting tumor causing secondary hypertension

A 25-year-old hypertensive female patient was referred to our institution. Initial workup exams demonstrated a 2.8 cm cortical lower pole tumor in the right kidney. She underwent laparoscopic partial nephrectomy without complications. Histopathologic examination revealed a rare juxtaglomerular cell tumor known as reninoma. After surgery, she recovered uneventfully and all medications were withdrawn. Case hypothesis: Secondary arterial hypertension is a matter of great interest to urologists and nephrologists. Renovascular hypertension, primary hyperadosteronism and pheocromocytoma are potential diagnosis that must not be forgotten and should be excluded. Although rare, chronic pyelonephritis and renal tumors as rennin-producing tumors, nephroblastoma, hypernephroma, and renal cell carcinoma might also induce hypertension and should be in the diagnostic list of clinicians. Promising future implications: Approximately 5% of patients with high blood pressure have specific causes and medical investigation may usually identify such patients. Furthermore, these patients can be successfully treated and cured, most times by minimally invasive techniques. This interesting case might expand knowledge of physicians and aid better diagnostic care in future medical practice.

Anatrophic Nephrotomy as Nephron-Sparing Approach for Complete Removal of Intraparenchymal Renal Tumors

Objective: Partial nephrectomy for small kidney tumors has increased in the last decades, and the approach to non-palpable endophytic tumors became a challenge, with larger chances of positive margins or complications. The aim of this study is to describe an alternative nephron-sparing approach for small endophytic kidney tumors through anatrophic nephrotomy. Patients and Methods: A retrospective analysis of patients undergoing partial nephrectomy at our institution was performed and the subjects with endophytic tumors treated with anatrophic nephrotomy were identified. Patient demographics, perioperative outcomes and oncological results were evaluated. Results: Among the partial nephrectomies performed for intraparenchymal tumors between 06/2006 and 06/2010, ten patients were submitted to anatrophic nephrotomy. The mean patient age was 42 yrs, and the mean tumor size was 2.3 cm. Mean warm ischemia time was 22.4 min and the histopathological analysis showed 80% of clear cell carcinomas. At a mean follow-up of 36 months, no significant creatinine changes or local or systemic recurrences were observed. Conclusion: The operative technique described is a safe and effective nephron-sparing option for complete removal of endophytic renal tumors.

Ovarian Borderline Tumor and Fertility-Sparing Surgery

Ovarian borderline tumors (OBTs) are frequently diagnosed in women of reproductive age. There is no consensus about their management, and it sometimes represents a dilemma aboutwhat should be done: fertility sparing surgery or a hysterectomy with salpingo-oophorectomy? Case: A 32-year-old nulligravida, diagnosed with a right ovarian borderline tumor is presented. She underwent pelvic washings, right salpingo-oophorectomy, appendectomy, and omental and peritoneal biopsies (laparotomic approach). Macroscopically, the left ovary was normal and subsequent exploration for staging was also normal, including the lymph nodes. Intraoperatively, frozen section examination was unclear, suggesting an OBT. Results: The final histopathologic diagnosis was ovarian borderline tumor, stage IIC (International Federation of Gynecology and Obstetrics [FIGO] staging). The patient expressed a desire to preserve her fertility. Thirty-six months postsurgery, she became pregnant spontaneously and delivered a healthy newborn at term. Conclusions: Conservative surgery can be performed in young patients treated for an OBT, provided they are closely followed up and that this surgery is performed after careful consideration and informed consent. It is, however, controversial with respect to performing hysterectomy and salpingo-oopherectomy upon the patient’s completion of childbearing.

Apport de l'utltrasonographie dans la chirurgie d'épargne du rein et du testicule [Benefits of ultrasonography in kidney and testicular-sparing surgery].

Renal and testicular cancers account for 4% and 1% of all malignancies, respectively. Their prevalence has increased over the past years and is related to the widespread use of medical imaging and the incidental findings of small asymptomatic tumors on computed tomography scanners and ultrasounds examinations. The urologist faces the dilemma of overtreating benign asymptomatic lesions with radical surgery. Therefore, organ-sparing surgery was developed. Recent studies have shown that recurrence rates are often similar between organ-sparing and radical surgery for small kidney or testicular tumors. However, the risk of positive surgical margins consecutive to organ-sparing surgery remains a matter of debate. This article discusses the role of ex-vivo peroperative ultrasonography in predicting negative surgical margins during kidney- and testicular-sparing surgery.

Kidney-sparing surgery for upper tract urothelial cancer.

PURPOSE OF REVIEW: This article reviews and summarizes current knowledge on kidney-sparing surgery (KSS) for upper tract urothelial carcinoma (UTUC). RECENT FINDINGS: Radical nephroureterectomy (RNU) has been central to the treatment of UTUC for decades, but KSS has been applied to a rising number of patients to preserve renal function. Ablation or resection through flexible ureteroscopy or the percutaneous route seems to provide comparable cancer-specific survival and overall survival to RNU, but the risk of local and bladder recurrence remains relatively high. Segmental ureterectomy is used for low-risk unifocal UTUC with recent studies confirming its oncologic safety and equivalence to RNU. Antegrade or retrograde instillation therapy may be considered as adjuvant treatment after conservative surgery, but their efficacy needs to be proven. Intravesical single-dose chemotherapy is likely to become part of the therapy algorithm of UTUC treated by KSS or RNU to lower bladder seeding and recurrence. Postoperative vigilant radiographic and endoscopic surveillance are obligatory because of the high probability of recurrence. SUMMARY: KSS should be regarded as a valid alternative to RNU in case of technically resectable low-risk upper tract urothelial cell carcinoma, even in case of a normal contralateral kidney. Advances in technology and biological and clinical risk estimation will make the management of UTUC more evidence based thereby lowering overtreatment.

Bilateral giant renal angiomyolipoma associated with hepatic lipoma in a patient with tuberous sclerosis

OBJECTIVE: To report a case of bilateral giant renal angiomyolipoma associated with tuberous sclerosis, with successful treatment, and to review the literature concerning angiomyolipoma treatment. CASE REPORT: Patient with tuberous sclerosis and angiomyolipoma diagnosed by ultrasonography during her pregnancy. At that time, the angiomyolipoma on the right side was 9 cm in diameter. Conservative management was selected during her pregnancy. The patient returned 7 years later, with a 24.7 x 19.2 x 10.7 cm tumor on the right side and another of 13 x 11.5 x 6.5 cm on the left side, in addition to multiple small angiomyolipomas. A nephron-sparing surgery with tumoral enucleation was performed on the right side, and after 3 months, the tumor on the left side was removed. Renal function in the post-operative period was preserved, and contrast medium progression was uniform and adequate in both kidneys. CONCLUSION: We conclude that an angiomyolipoma larger than 4 cm should be removed surgically, since they have a greater growth rate and pose a risk of hemorrhage. Resection of smaller tumors is safe and has decreased morbidity. Tumoral enucleation is an effective treatment method that preserves kidney function.

Repeated surgical excision for an unusual variant of nephroblastoma: case report and review of the literature.

Bilateral fetal rhabdomyomatous nephroblastoma is a rare variant of Wilms' Tumor. The authors report the evolution over 48 months of a 10-month-old baby with bilateral nephroblastoma for which a left nephrectomy was initially performed. A right kidney tumor was enucleated preserving the kidney. The transformation of the primary tumor into a completely differentiated cystic nephroblastoma or nephromalike tumor and the appearance of a metachronous lesion was seen. This report emphasizes the role of nephron-sparing surgery in bilateral Wilms' Tumor when a benign transformation occurs under chemotherapy.

Diagnosis and Management of Upper Tract Urothelial Carcinoma.

While UTUC is relatively uncommon, it has an aggressive natural history and poor prognosis, which has not substantially improved over the past two decades. Nevertheless, continued research has led to the discovery of risk factors improving the prevention and early detection of UTUC. Although RNU remains the standard treatment for localized invasive UTUC, nephron-sparing surgery for selected patients has made considerable progress in the recent years. The stagnation in the prognosis of UTUC over the past two decades highlights the necessity for incorporating multimodal approaches including refinements in systemic chemotherapy and radiotherapy to attain better outcomes for patients with UTUC.

Experiencia con la realización de nefrectomía parcial para el tratamiento de masas renales : estudio multicéntrico

Objetivo: Reportar la experiencia obtenida con la realización de Nefrectomía Parcial para el tratamiento de masas renales en la Fundación Santa Fe de Bogotá y Fundación Cardioinfantil. Materiales y Métodos: Se revisó el registro de procedimientos quirúrgicos de las dos instituciones entre enero de 2005 y marzo de 2011. Se incluyeron los pacientes llevados a nefrectomía parcial y se revisaron las historias clínicas. Se excluyeron pacientes operados por patología no tumoral. Se registraron variables preoperatorias, intraoperatorias y postoperatorias. Se creó una base de datos en Excel y se elaboró un análisis descriptivo de las variables utilizando el paquete estadístico Stata 10.0. Resultados: Se realizaron un total de 63 nefrectomías parciales. Se analizaron 59 que fueron realizadas por sospecha de patología tumoral (quistes complejos o cáncer). El promedio de edad fué 60.7 años. En los pacientes con sospecha de tumor renal, la principal indicación para el procedimiento conservador fue el tamaño de la masa (82.53%). La creatinina preoperatoria fue 1.01 mg/dl en promedio. El abordaje utilizado con mayor frecuencia fue la lumbotomía (89.8%). En 79.6% de los casos se realizó isquemia fría. El sangrado fue 354 cc en promedio. En 6.77 % de los pacientes fue necesario ampliar el margen. El diagnóstico definitivo más frecuente fue carcinoma de células claras en el 72.8% de los casos. La creatinina postoperatoria fue de 1.14mg/dl en promedio. Un 98.3% de los pacientes permanecen libres de recaída con un seguimiento promedio de 27 meses. Conclusiones: La nefrectomía parcial por abordaje a cielo abierto es un procedimiento oncológicamente efectivo, con baja morbimortalidad y que permite mantener la función renal, en manos experimentadas. Es considerada el patrón de oro para el tratamiento de masas renales en estado T1a, tumores bilaterales, en pacientes con falla renal o en aquellos que tengan enfermedades que potencialmente la afecten.

Supervivencia cáncer específica posterior a nefrectomía radical frente a nefrectomía parcial en carcinoma renal t2: revisión sistemática

Introducción: El tratamiento estándar para los tumores renales localizados es la nefrectomía radical, sin embargo debido a la variación el tamaño del tumor renal en el momento del diagnóstico, se ha reemplazado en algunos casos por la nefrectomía parcial. Objetivo: Este estudio busca comparar el resultado oncológico de la nefrectomía parcial en términos de supervivencia cáncer específica, respecto a la nefrectomía radical, en pacientes mayores de 50 años con carcinoma renal estadio II (T2N0M0) Métodos: Se realizó una revisión sistemática de la literatura, con inclusión de estudios de casos y controles, cohortes y experimentos clínicos aleatorizados incluidos en las bases de datos de MEDLINE , EMBASE y CENTRAL Resultados: La búsqueda inicial emitió un total de 101 resultados, 11 artículos fueron preseleccionados y sólo un artículo cumplió con los criterios de selección; éste se clasificó como nivel de evidencia II. Conclusión: No fue posible concluir su equivalencia oncológica de la nefrectomía radical con la nefrectomía parcial, dado que no hay diseños de estudios que permitan llegar a esta conclusión.

Organ-Sparing Microsurgical Resection of Incidental Testicular Tumors Plus Microdissection for Sperm Extraction and Cryopreservation in Azoospermic Patients: Surgical Aspects and Technical Refinements

INTRODUCTION The management of nonpalpable testicular masses is a challenging task, and coexisting infertility can further complicate the treatment decisions. We present our technique for microsurgical organ-sparing resection of incidental nonpalpable testicular nodules combined with microdissection for testicular sperm extraction and tissue cryopreservation in azoospermic patients. TECHNICAL CONSIDERATIONS Five infertile patients with azoospermia presented with nonpalpable hypoechoic testicular masses that were detected by Ultrasonography and underwent organ-sparing surgery. The testis was delivered through an inguinal incision, and the blood circulation was interrupted with a vascular clamp placed on the spermatic cord. Sludged ice was used to prevent warm ischemia, and a temperature probe was used to control the temperature at 12 degrees-15 degrees C. Real-time reflex ultrasonography was used to locate the tumor, and a stereotaxic hook-shaped needle was inserted under ultrasound guidance. The needle was placed adjacent to the tumor to guide the microsurgical resection. The tunica albuginea was incised over the tumor, which was dissected and removed, along with the adjoining parenchymal tissue. Frozen section studies were performed and, if malignancy was confirmed, biopsies of the tumor cavity margins and remaining parenchyma were obtained to ensure the absence of residual tumor. Microdissection was performed for excision of selected enlarged tubules that were processed and cryopreserved. CONCLUSIONS We present a technique for microsurgical organ-sparing resection of testicular tumor and sperm extraction that can be used in selected infertile patients with azoospermia in whom incidental masses have been diagnosed by ultrasonography. This conservative approach should be especially considered for patients with a solitary testis or bilateral tumors. UROLOGY 73: 887-892, 2009. (C) 2009 Elsevier Inc.

Experiencia en nefrectomía: serie de casos de cuatro años

Introducción: Las indicaciones por las cuales un paciente requiere una nefrectomía son múltiples: las neoplasias, la hidronefrosis y la exclusión funcional son las principales. En manos expertas la nefrectomía es un procedimiento seguro, especialmente porque en la actualidad el abordaje por excelencia es realizar una técnica mínimamente invasiva con conservación de nefronas. Se presenta el análisis de la experiencia en Mederi, Hospital Universitario Mayor en esta intervención. Metodología: Se realizó una serie de casos de pacientes llevados a nefrectomía entre mayo de 2008 y mayo de 2012. Se incluyeron la totalidad de los casos. Resultados: Se analizaron 72 registros, 49 mujeres y 25 hombres; 13 de ellas fueron laparoscópicas. La edad promedio fue de 58,6 años. El tiempo medio operatorio fue 169,23 minutos (118-220 minutos). El sangrado operatorio promedio fue de 680,63 ml (IC95%: 2,83-1358 ml). El tiempo de hospitalización promedio fue de 4,88 días IC95%. La mayoría de los pacientes se distribuyeron en estadios medios de la enfermedad tumoral, con poco compromiso ganglionar y metástasis; el diagnóstico histológico y estadio dominante fueron el carcinoma de células renales grado 3 de Fuhrman respectivamente. Se reportan 13 casos de compromiso de la capsula de Gerota y 11 con compromiso del hilio. Discusión: La experiencia en nefrectomía de la institución es muy positiva por el bajo número de mortalidad y complicaciones. En cuanto a la técnica, es importante promover la técnica laparoscópica